Dental Emergencies

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Dental Emergencies Powered By Docstoc
					Dental Emergencies
   Scott Farquharson
     Sept 24th 2009
           Topics Covered
 Dental trauma
 Dental infections
 Dental blocks
 Pediatrics
                 Dental Anatomy
   Primary
       Eruption from 7-30 months
       20 teeth, 10 upper, 10 lower
       2X ( 4 incisors, 2 canines, 4 molars)
   Permanent
       Begin formation 3-4 months
       Eruption 7-21 years
       32 teeth ( including wisdom teeth)
       2x ( 4 incisors, 2 canines, 4 premolars, 6 molars)
Dental Anatomy
              Dental Trauma
 Fractures  of teeth
 Alveolar Fractures
 Luxation
 Intrusion or concussion
 Avulsion
 Primary vs Permanent
 Fractures of Permanent Teeth
 Enamel    (Ellis 1)
     Chipped tooth
     Painless unless associated with other injuries
     Large chips can be saved for reattachment
     Non urgent dental referral for cosmetic
 Fractures of Permanent Teeth
 Enamel     and Dentin ( Ellis 2)
     70 % of dental fractures
     Pain with hot or cold
     Dentin is yellow colored
     Panorex to R/O other injury
     Increased risk of pulp infection/desiccation
     Dental evaluation in 24hrs
     Protection with dental cement
     Consider antibiotics
 Fractures of Permanent Teeth
 Pulp   involvement
     May be visible (Ellis 3)
       • Can see blood
     May be below gums (root fracture)
       • Only seen with x-ray
     Very painful as nerve exposed
     Treatment as Ellis 2
     Will need extraction or root canal
      Fractures of Permanent Teeth

 Alveolar   Fractures
     Associated with fractures, luxated or avulsed
      small fractures involving 1 or 2 teeth can be
      treated by a dentist
     Large areas of alveolar bone damage can
      cause significant cosmetic deformity and oral
      surgery should be consulted
Root Fracture
   “Loose tooth”
   Extrusion – dislodgement from alveolar bone
   Lateral luxation – lateral displacement with
    alveolar fracture
   Both should have x-rays
   Reposition with firm pressure – may require
    local anesthesia
   Temporary splinting in ED
   Permanent splinting/treatment by dentist
     Concussion and Intrusion
 Displacement     of tooth into socket
 Concussion – pain with no movement
 Intrusion – more severe displacement
  involving root fracture and/or alveolar
 Intrusion is differentiated on x-ray and
  requires repositioning
   Complete displacement of tooth from alveolar
   Best chance of saving tooth if reimplanted in
    under 3 hrs
   Transport in sterile saline, milk, Hank solution or
    in buccal sulcus not ice or water
   Avoid disruption of periodontal ligament fibers
    on root
   Clean with normal saline
   Rinse clot from socket
   splint
       Primary Vs Permanent
 Avulsed primary teeth should not be reimplanted
  to avoid damage to underlying teeth
 Primary teeth have more pulp and less dentin
  and are more at risk for infection
 Luxations in young children are at greater risk of
  avulsion and aspiration – consider urgent dental
 Enamel injuries can cut mucosa in young
  children and may need to be filed down
            Final Thoughts
 Pen or amoxicillin usually sufficient
 Consider clindamycin or EES if allergic
 Don’t forget tetanus immunization
            Dental Infections
 Periapical  abscess
 Pericoronitis
 Dry socket
 Buccal/facial cellulitis
 Complications
         Periapical Abscess
 Complication   of carries/pulpitis
 Inflammation and abscess formation in
  periodontal and buccal tissues
 lymphadenopathy
 Streptococcus mutans
 Painful – relieved by I&D
 Definitive treatment is root canal (removal
  of the pulp and filling of the empty pulp
  chamber and canal )
Periapical Abscess
Periapical Abscess
 Most  common in wisdom teeth
 bacterial plaque and food debris
  accumulate beneath the flap of gum
  covering the partially erupted tooth.
 Pain, bad taste, pus, local inflammation
 can progress to cellulitis
 Salt mouthwashes, irrigate under flap
  Dry Socket- Alveolar Osteitis
 Complication  of tooth extraction
 Clot covering alveolar bone is displaced
 Exposed alveolar bone becomes inflamed
 Normal post extraction pain decreases
  over 48hrs
 Dry socket pain increases at 24-72 hrs
 Can progress to osteomyelitis
                  Dry Socket
 Analgesia     – Nsaids, Narcotics, Nerve
 Referral back to dentist in 24 hrs
     Will need frequent packing
 ABX?
     If caught early and timely follow up is
      available probably not needed
   Dental infections can progress to life threatening
       Facial or buccal cellulitis
       Submandibular space infections (Ludwig’s angina)
       Parapharyngeal space infections
       Airway compromise
       Orbital infections
       CNS infections
       Mediastinal infections
       Cavernous sinus thrombosis
   Signs of more serious illness
       Systemic symptoms – fever/chills
       Trismus
       Displacement of tongue
       Altered LOC/delirium
       Eye pain
 Require systemic ABX
 ENT consult
 Possible CT imaging
 Airway management
   Broad range of pathogens
       Mainly streptoccocal
       Bacteroides sp.
       Anaerobes
   Simple infections
       Pen V or amoxil
       I prefer Amox/Clav or clinda
 Infections extending to facial or buccal cellulitis
 IV 2nd generation cephalosporin + metronidazole
          Dental Nerve Blocks
 Supraperiosteal     nerve block
     Anesthesia for individual tooth
 Inferior   Alveolar Nerve Block
     Anesthesia for lower teeth
     Supraperiosteal Nerve Block
   Select the area to be anesthetized and dry it with gauze.
   Ask the patient to close the jaw slightly to relax the facial
   Grasp the mucous membrane of the area with a piece of gauze.
   Pull the gauze (and the mucous membrane) out and downward in
    the maxilla and out and upward in the mandible to extend the
    mucosa fully and to delineate the mucobuccal fold.
   Puncture the mucobuccal fold with the bevel of the needle facing the
   Aspirate the area and then deposit approximately 1 to 2 mL of local
    anesthetic at the apex (area of the root tip) of the involved tooth.
   It is helpful to place a finger against the outer aspect of the lip
    overlying the injection site and apply firm and steady pressure
    against the lip while slowly injecting the local anesthetic into the
    supraperiosteal site
Supraperiosteal Nerve Block
Supraperiosteal Nerve Block
Inferior Alveolar Nerve Block
    Inferior Alveolar Nerve Block
 Palpate the retromolar fossa with the index
  finger or thumb.
 Identify the greatest depth of the anterior border
  of the ramus of the mandible (the coronoid
 With the thumb in the mouth and the index finger
  placed externally behind the ramus, retract the
  tissues toward the buccal (cheek) side, and
  visualize the pterygomandibular triangle.
       This technique also moves the operator’s finger safely
        away from the tip of the needle.
Inferior Alveolar Nerve Block
    Inferior Alveolar Nerve Block
   Hold the syringe parallel to the occlusal surfaces
    of the teeth and angled so that the barrel of the
    syringe lies between the first and second
    premolars on the opposite side of the mandible.
       Achieving the proper angle is important to the
        success of this block.
       If a large-barrel syringe is used, the corner of the
        mouth may hamper efforts to obtain the proper angle.
       Carefully bend the 25-gauge needle about 30
        degrees to facilitate achieving the proper angle. The
        needle cap can be used to bend the needle
    Inferior Alveolar Nerve Block
 Make the puncture for the injection in the
  pterygomandibular triangle, at a point that is 1 cm above
  the occlusal surface of the molars.
 If the needle enters too low (e.g., at the level of the
  teeth), the anesthetic will be deposited over the bony
  canal and prominence (lingula) that house the
  mandibular nerve, and not over the nerve itself.
 There may be slight resistance as the needle passes
  through the ligaments and the muscles covering the
  internal surface of the mandible. When there is more
  solid resistance, the needle has reached the bone.
 Stop when the needle has reached bone, which signifies
  contact with the posterior wall of the mandibular sulcus.
 It is important to feel the bone with the needle (
Inferior Alveolar Nerve Block
   Inferior Alveolar Nerve Block
 Itis important to feel the bone with the
 After reaching the bone, withdraw the
  needle slightly and aspirate to check for
  possible intravascular placement.
 Deposit approximately 1 to 2 mL of
  anesthetic solution; 3 to 4 mL of anesthetic
  may be required if needle positioning is
Inferior Alveolar Nerve Block
  Inferior Alveolar Nerve Block
 Failureto feel bone as the needle is
 advanced generally results from directing
 the needle toward the parotid gland (too
 far posteriorly) rather than toward the inner
 aspect of the mandible. Injecting into the
 parotid gland can anesthetize the facial
  Inferior Alveolar Nerve Block
 One  may anesthetize the lingual nerve by
 placing several drops of anesthetic
 solution while withdrawing the syringe.
 The anterior two thirds of the tongue can
 thus be anesthetized. In actual practice,
 the lingual nerve is consistently blocked
 with this procedure owing to the close
 proximity of both nerves.
     Inferior Alveolar Nerve Block
   Complications include inadvertent administration of
    anesthetic posteriorly in the region of the parotid gland,
    which will anesthetize the facial nerves. This is an
    annoying but relatively benign complication that will
    cause temporary facial paralysis (similar to Bell’s palsy)
    affecting the orbicularis oculi muscle and results in
    inability to close the eyelid. Should this occur, the eye
    must be protected until the local anesthetic has worn off
    (approximately 2 to 3 hours), and the patient must be
    reassured. Anesthesia with bupivacaine (Marcaine)
    presents a more significant problem if this complication
    occurs, because bupivacaine anesthesia lasts from 10 to
    18 hours in some patients.

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